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Navy Pilot's Medical Mystery Solved by Three Stanford Experts

07.08.2014

Before he came to Stanford Hospital for care, U.S. Navy Cmdr. Robert Buchanan endured six years of painful symptoms that kept him grounded from flight.

Stanford's laryngology division chief, Ed Damrose, has nearly 20 years of practice under his belt, but what he observed in U.S. Navy Cmdr. Robert Buchanan stumped him. "I had never encountered anything quite like it before," Damrose said.

When he had done what he could, he sent Buchanan to Jayakar V. Nayak, MD, PhD, one of Stanford's top specialists in the workings of the nasal cavity and sinuses. After Buchanan shared his symptoms with Nayak, he, too, was struck by what he was seeing.

Nayak thought some of Buchanan's issues might be related to a problem with his left tear duct, so he called Andrea Kossler, co-director of the Ophthalmic Plastic, Reconstructive Surgery and Orbital Oncology Service at the Byers Eye Institute at Stanford. She looked at Buchanan and agreed with Damrose and Nayak. Whatever it was that was plaguing Buchanan "was something we had never seen," Kossler said.

What these three expert doctors were chasing was an explanation for air, harmless when it stays where it is needed. Buchanan, however, came to Stanford with a painful constellation of symptoms that seemed to be caused by air rushing into places where it was not meant to be. Before he arrived at Stanford, Buchanan had gone from doctor to doctor—dozens, in fact—hoping for treatment and finding none. Sometimes, he was told, "Learn to live with it." Sometimes, he was doubted. "I knew myself well enough to know I wasn't crazy," Buchanan said. "There was something physiological happening to me."

What no one could explain was how to find that misplaced air and the painful symptoms it was causing: an irregular heartbeat and a cluster of issues on his left side—a drooping eyelid, dissimilar-size pupil, sensitized sinus on the left face, jaw pain and neck swelling.

Not oxygen deprivation, but decompression injury

Buchanan was flying back to an aircraft carrier in the Middle East when a sudden surges of decompression left him unconscious while his plane dropped thousands of feet.

Buchanan had lived most of his adult life as a U.S. Navy aviator, flying combat jets at hundreds of miles per hour at thousands of feet in the air. By the time he arrived at Stanford, he had been grounded from flight since March 20, 2006, a day that changed everything for him.

Flying back to the aircraft carrier after a mission, he began to notice some powerful decompression surges in the normally pressurized cockpit of the jet. He was wearing an oxygen mask, and, as all aviators do, knew how to react to the symptoms of oxygen deprivation. What he was feeling was very different. "I remember the feeling of incapacitation," Buchanan said, "and then there was some sort of lapse."

Buchanan managed to land his aircraft, but not without help—and then the medical mystery began.

When his awareness faded out, he was flying at about 27,000 feet above the sea and 450 miles from the nearest U.S. Air Force base. At 9,000 feet, Buchanan regained consciousness to the voice of a fellow pilot, flying nearby, repeatedly yelling his call sign over the radio. Buchanan with help, managed to fly back to the aircraft carrier. He remembers getting out of the plane and having a hard time keeping his balance.

Doctors determined that Buchanan had suffered a decompression injury—from what divers call the bends. Caused by a rapid decrease in environmental pressure, decompression injury prevents the body from clearing gases from the lungs. Those gas bubbles can travel throughout the body, producing permanent injury if not treated.

The extra air traveling Buchanan's body meant something was very wrong. Doctors looked at one of his tearducts as a possible conduit.

At Stanford, Damrose evaluated Buchanan and found an air-filled sack in Buchanan's neck that doctors usually see appear after gunshot wounds to the neck or fractures of the facial bones—not after a decompression injury. "We felt this was a strange presentation of a common phenomenon," Damrose said. He believed that air was traveling toward Buchanan's eye and brain, into his vestibular system, a nest of canals and capsules in the inner ear, and back down into his chest.

Air escaping throughout the body can kill a person.

-Ed Damrose, MD

Relentless pursuit to end mysterious symptoms

He removed that small capsule from Buchanan's neck, but Buchanan's symptoms continued and the mystery remained. Damrose looked again, this time at Buchanan's esophagus, lungs and voice box. "Once we knew where the air was not coming from, we were concerned about where it was really coming from," Damrose said. "We looked everywhere that would be expected, and we could not find a source."

Nor did an extensive search of medical literature and consults with colleagues at other medical institutions reveal any clues. Nayak was next. "I needed somebody who could take a fresh look at the evidence and say, 'This might be something new that we've not encountered before,'" Damrose said. Nayak looked at Buchanan's CT scans and found only changes in his sinus typical of those from years of high altitude flying.

Bit by bit, Nayak explored the interior cavities of Buchanan's face and skull. "There were areas that looked entirely normal, but if you touched them, they were exquisitely tender," Nayak said. First, he repaired the damage from that high altitude flying.

Dr. Nayak told me it looked as if a bomb had gone off in my sinuses.

-U.S. Navy Cmdr. Robert Buchanan

What happened next was a medical game of hide-and-seek: Nayak would block one suspected avenue of air and another would emerge. He proceeded cautiously, patching, one by one, portions of Buchanan's sinuses. Finally, Nayak cut out that particularly sensitive piece of Buchanan's sinus and, in a surgical first for him, borrowed other sinus tissue to cover the holes. For a month, the somewhat unorthodox fix worked. But as had happened before, a new symptom developed in the tear duct of Buchanan's left eye. Kossler suspected that the tear duct, abnormal in size, was allowing air to pass into Buchanan's nose, into the deep tissues of the face and then to his neck. She also found in the tear duct a pocket of soft, moist tissue that had trapped air and removed that.

Many of the procedures that we ultimately performed did not have formal names and had not been previously performed, so we had to be creative about extending principles of surgery and tissue reconstruction to meet this patient’s most unusual predicament.

By this time, the team working on Buchanan had expanded to included several other Stanford doctors in relevant specialties, including anesthesiology and thoracic surgery, all looking for corridors for air passage in the head, neck and respiratory tract. Finally, up against a timeline the military had set for Buchanan to return active duty, the team decided to try a staged set of experiments. Kossler and Nayak surgically created a new, higher tear duct drainage port to bypass his malfunctioning and sensitive tear duct. Damrose then used a laser for a quick corrective surgery to treat an area of pain at the base of his tongue. Then, in a set of separate procedures, Nayak placed human tissue-based graft sheeting between Buchanan's sinuses and the deep tissues of his face—the fifth and sixth patching procedure in that area of high sensitivity. "We all agree that we don't 100% know why it all worked, but together it worked," Kossler said. This combination of successive treatments worked for such a long time that Buchanan was able to go through the U.S. Navy simulator tests that would determine if he could fly again.

Moving on, protecting others

This winter, eight years after his near-fatal flight, two years after he came to Stanford for help, after a slew of diagnostic tests and more than a dozen incremental surgeries to fix his injuries, Buchanan qualified to fly again. With that step, he can move toward commanding a squadron of fighter pilots. "That's the pinnacle of an aviator's career," he said.

"This case taught me to never, never take it for granted that you know it all," Damrose said. "The answers aren't always in textbooks." The literature search also revealed other patients suffering from similar symptoms, almost all related to decompression injury, he said. "And Cmdr. Buchanan spurred us to keep going."

"Many of the procedures that we ultimately performed did not have formal names and had not been previously performed," Nayak said, "so we had to be creative about extending principles of surgery and tissue reconstruction to meet this patient’s most unusual predicament." Kossler, earlier in her practice than Damrose and Nayak, also acquired some important takeaways. "When you finish your training, you think you know everything," she said, "but the more you learn, the more you learn that you don't know everything. In this case, we put our minds together and didn't give up."

That will likely make a difference for others. "Through this process, we learned of two other Navy pilots with similar decompression injuries that hadn't been previously reported," Kossler said. Buchanan helped uncover new knowledge about such a decompression injury. "It had never been in the emergency procedures book before, but now it's an action item that pilots have to memorize and are tested on routinely," he said. "The Navy's done a fantastic job of realizing that this is something we can do better, to help aviators as we put them in harm's way."

Those Stanford doctors did have to come up with a name for this now-identified decompression injury. It doesn't exactly roll off the tongue, but it's finally part of medicine's lexicon: a sino-cervical fistula.

Nayak is waiting for one small token of thanks he wants from Buchanan. "I want to him to call me from somewhere higher than 20,000 feet, from the cockpit of his F-18, doing what he does best and what he loves to do."

The opinions contained in this presentation are solely those of CDR Buchanan and are not intended to represent the opinions of the Department of Defense, Department of the Navy or any part of the United States Government. Furthermore, the opinions and information contained in this presentation should not be construed as implying an endorsement of any organization by the Department of Defense, Department of the Navy, or any part of the United States Government.

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